Wag & Company

Referral Made By

Referral contact name *

Referral Organisation

Organisation Type *

Organisation *

Department or Team

Organisation postal address *

Address first line *

Address second line

Postcode *

Town *

Referral Contact Details

Email *

Re-enter Email address*

Work telephone *

Mobile telephone

Visitee Details

Title *

First name *

Last name *

How does he/she prefer to be addressed? *

Gender *

Date of birth * Age:

Status *

How long have they been living alone?

Please provide supporting info, e.g. wife died 3 years ago

Home address *

Address first Line *

Address second line

Postcode *

Town *

Please check and confirm that the address has been input correctly *

Type of accommodation *

Is this their own home? *

If not please provide details i.e. sheltered accommodation or assisted living or living with family and contact details for the primary home owner

Is there a working landline at the property? *

If so please include the telephone number

Is there mobile telephone signal at the property? *

Parking Advice: Is there a car parking space, a drive or is there on street parking, please provide details *

Do you feel safe to visit this address alone? *

If not, please explain why

Are there, or have there recently been, any other pets in the property, eg a cat *

If so can you please describe the pet and confirm if applicable that they do not have fleas and receive veterinary recommended flea treatments at the required intervals

Does he/she have any mobility limitations? *

If so please provide details

Can he/she leave the house independently or at all? *

Please provide details

Does he/she have any other health challenges? *

If so please provide details

Are they a smoker? *

Are they happy to adhere to our smoking policy: not to smoke 2 hours prior to a visit or during a visit and to ventilate / open windows. *

Does he/she have any memory or judgement loss? *

If so how does that affect them in practice?

In your opinion would you judge he/she to have capacity for consent for the use of photographs for instance? *

Emergency Contact

Emergency contact name *

Emergency contact mobile/daytime number

Emergency contact email

Emergency contact notes

Who are they in relation to the person we'll be visiting? *

Where do they live? *

Is the emergency contact aware a referral has been made? *

Are you going to arrange for them to be present at the first visit? *

Risk Assessment Details

Please provide the details of the risk assessment that has been carried out to enable lone working in these circumstances ie with this person, at this location and inside this home. *

Could anyone else - a person or an organisation (eg carers) - be in the house when we visit? *

If so please provide full details including the relationship to the person we are visiting or if another organisation please provide the name of the agency and the contact telephone number

Dog History Details

What type of dogs has he/she owned in the past? *

When did they lose their last dog? *

Referral Details

Please explain in full the reasons for the referral and the desired outcome from our visits *

Preference and Other Information

Is there potential for another dog (belonging to a relative or friend) to be visiting at the same time *

If so please provide likely visiting days and times

Is there any day or time where our visits would not be possible? *

If so please provide details

Does he or she have any particular requirements or preferences? e.g. male or female visitor, specific dog breed/type? *

If so please provide details

Is there any other useful information about the person or the premises our special befriending team should be aware of? *

If so please provide details